When it comes to running a program for people with brain injuries, have you ever asked yourself what background skills are the most essential for your employees? I think most of you would lean toward the traditionally trained CNA (certified nurse’s aide). But, at Intellegis, we see it differently. As I think back upon some of the very best employees I ever hired, one positive trait comes to mind. The most effective staff; the most able to earn the trust and respect of our residents have been those excelling at customer service. Now, don’t get me wrong, we definitely need the skill set of a CNA to carry out the proper care and follow up from the therapists. In fact, it is requirement for our staff to be CNA certified. But, CNA – CS = Escalation!

In our opinion, the number one, most crucial, vitally important need for a resident living in one of our homes is staff interaction. (I should say it in all caps!) Positive staff interaction is the best indicator for reduced escalation and frustration among our residents. When a resident is genuinely fond of a staff member, they are less likely to feel frustration and anger. Those emotions almost always come into play, but are less likely to occur with interaction focused staff. Think of it this way. Imagine you have a brain injury significant enough to warrant living in a community based program. Now picture a dedicated staff that cares for your every need, but doesn’t really communicate much with you or allow time for the things you want to talk about. Some staff may even be so dedicated to their care agenda that your emotional needs become an afterthought. Isn’t this what often happens in Nursing Homes where the staff to client ratio is so high that there’s no time for human interaction? In those instances, it’s not that the staff don’t truly care for the client, but rather their focus is on handling all care needs in a way that is able to get all the required things done, on time. And, in some cases, the traditional CNA does not neccessarily even have the customer service skill set. It makes sense however, because often a person pursuing work as CNA enjoys the routine of things and carrying out orders. However, there may be a stark contrast when it comes to the often abstract world of customer service when compared to the somewhat concrete world of the CNA.

Customer service, though it may be learned, is a skill most often developed by a person’s core beliefs. According to Ubuntu (African Philosophy)“There exists a common bond between us all and it is through this bond, through our interaction with our fellow human beings, that we discover our own human qualities.” In other words, the desire to interact with others in a meaningful way generally comes from people with an affection for humanity. You can spot these qualities in a job interview as evidenced by warmth, eye contact, friendliness and positive, thoughtful conversation. You’ll know when you have people with these qualities by the way you feel after the interview. It’s the difference between ‘he or she will do’ vs. I’m excited about hiring this person. A customer service oriented person genuinely cares about the person they are serving and as such doesn’t need to be admonished to talk more; interact more and show more interest.

Recently, one of my former staff (who rightfully left for a position with greater opportunity) stopped by to visit me. As he and I were talking, one of our residents came in. The resident could barely contain his excitement at seeing this person. He smiled big, gave him a heartfelt hug and asked how he was doing. Instantly you could tell that the former employee had made a lasting connection with the resident, though he hadn’t been near our facility for roughly 6 months. That is customer service in a nutshell!

In order to be successful in transitioning brain injured residents back into the community, it is required that the home environment be a home environment where people talk, share feelings and interact. Care, though vital and necessary, must be blended with a healthy dose of humanity evidenced by skillful customer service. When what the resident needs becomes the number one priority, both physical care and emotional care will be a given.

So how do you know if you have hired a person with the proper skill sets for working with the ABI/TBI population? Simple ~ how do the residents react when they see them… CNA + CS = HFR (happy and fulfilled residents)…

I don’t know about your experience, but it seems most programs nowadays have an antiquated relic called, “Day Training.” I think Day Training first got its start in programs for seniors. I’m sure you have seen nursing homes with a group of seniors sitting around playing games or singing songs, attempting to actively engage residents in some type of activity. And maybe in that setting, there is some usefulness to such a program, but to carry that format into other types of programs seems very ineffective.

First I would assume that seniors have most likely reached retirement age and are no longer working. After many years of living and working it might be time for a break. Plus, by nature an older person may not be as active as their younger counterparts. But let’s carry that theme into programs that don’t have their focus on the senior population. Residential Support programs for people with brain injuries typically have a diverse range of ages and cognitive abilities. Each person has unique needs in terms of stimulation and productivity. So where did we ever get the idea such a unique population would need to be constantly entertained with games and outings and fun, fun, fun? My guess is the carryover from those senior programs mentioned earlier.

The reality is that “real life” does not involve fun and games all day, but instead a need to be useful and produce. So by switching the focus from “being entertained” to a focus on productivity, we perhaps unknowingly offer our residents access to a greater need being met. At Intellegis LLC, we have found that a productive, useful resident is a happy resident. Does that mean there is no fun? Of course not. Instead, fun is blended in with necessary things getting accomplished just as it works for the rest of the world. One of our residents has taken responsibility for the landscaping and lawn care. He owns that responsibility and works hard to make sure it is the best. And what do you suppose happens every time someone comments on how beautiful the lawn is? Our resident beams with pride and receives the satisfaction that comes from working hard.

A better approach to the old Day Training model is to design a program that involves work related activities, depending upon the person’s cognitive level and then reserve the fun activities for the evenings and the weekends. This approach more closely replicates “real life” and offers our residents the potential to remain both productive and “feeling” useful. Now it is important that the activities designed are not just busy-work, but rather work that is both needed and benefits the group as a whole. Busy-work would be an insult to a person’s dignity and well being. Surely there are enough needs in the larger group homes to offer each person their share of the overall contribution. So, be it setting the table for dinner or mowing the lawn, work has its own reward far exceeding its requirements in terms of time and energy.

It’s time to rethink the old Day Training model and come up with programs that more closely replicate real life experiences!

I’m often amazed how people are treated when they happen to become residents in various residential support programs or facilities. Once a person assumes the title, “resident” the rules change for him or her. Suddenly they are no longer a person with the same wants and needs that you and I have. In fact, their individual needs as a human being are somehow traded in for the “rules” of that particular facility! For example, “Breakfast is at 7:00 a.m.” Every day breakfast is at 7:00 a.m.? Well, what if the person wants to sleep in one day? I mean you and I can choose to sleep in one day, right? But, oh no, not the “resident.” The resident must be up at 6:00 a.m., showered by 6:30 a.m. and the dining room, by God, for breakfast by 7:00 a.m. Whether or not they like it is inconsequential. What matters is the facility rules…end of story.

Being a Program Administrator, I certainly understand the financial considerations of staffing, scheduling etc. But, what I can’t wrap my mind around is the lack of consideration for people not being treated like human beings. No we don’t have the staffing to man the dining room all day long, but isn’t there a better solution? It seems to me (and you may call me crazy), that the people living in our programs should be able to get up whenever they choose. And can we not figure out some alternative meal for the guy that got up at 9:30 a.m. The same sort of logic applies to bedtime. Again, what time do you go to bed? My guess? Exactly whenever you want to! Can you even imagine some 22 year old staff member telling you it is lights out at 10:00 p.m.? And we wonder why our people tend to escalate. They escalate because they are adults who have probably spent considerable time making their own choices. Just because they were forced to move to your facility does not mean they stopped being adults. People with Alzheimers are still adults. People with brain injuries that are older than 18 are still adults. Elderly people in their sunset years are still adults! Something is wrong with our philosophy, I think.

How about that dreaded adult activity called sex? We have the audacity to get flabbergasted when we find resident A in bed with resident B. Moralistic considerations aside, that is sort of what adults do, isn’t it? Yet in the facility it is reportedly a “no-no!” I remember one of my staff telling me once, “Such and such is in his room with his girlfriend and they have the door shut!” (Lord help us quick!) I responded, “Well good, make sure you don’t go in there (as that is generally what the door closed symbol means!). Sure I know we can’t have some kind of hippy-free love thing going on, but we ought to take into consideration that adults have needs and who are we to stifle them? Really, if we are doing our job with a serious commitment to human needs being met, we should encourage people to get their needs met in ways that are, of course, decent and considerate of the other humans. That’s how we do it in real life, yes?

Now, here is the ultimate shocker! What about alcohol? Oh no – don’t you even go there! Again, we are talking about human beings, right? Can you have a glass of wine when you get home from work? If you are an attorney, you can have one at work (smile). What about a beer? It seems you may do so if you so desire. So, where did we ever get the idea that facilities needed to be “lock-down” centers when it comes to alcohol? We got the idea because the thought of alcohol at work just doesn’t seem right; introduces potential liability and thus we pass along that concept to people who have the misfortune to live with us. I recognize that certain “residents” are on many types of drugs. Alcohol and drug interaction is a serious thing. But, why don’t we run that idea by the treating physician? Maybe 2 beers wouldn’t make a difference? Maybe it would? But the all encompassing “no alcohol” rule, well maybe that is a little much for (here it comes) “adults!” We manage liability successfully in a multitude of realms at work like driving vehicles, safety rules, behavior support training, but when it comes to alcohol we default to – no way! It seems the same care we take in making sure Mr. Jones with the brain injury doesn’t costume too much food because his “I’m full valve” isn’t working, could be taken in making sure we regulate the alcohol intake in light of potential drug interactions. Ya think?

We need to take a fresh look at how we interact with the people in our programs. We need to stop seeing them as “labeled adults” and get back to seeing them as simply, “adults.” Human beings require a humanistic approach and the sooner we can make that happen, the better we become at providing true residential support!

Have you ever been at one of those institutions where the number one priority is following the schedule that has been appointed for the staff? Typically an organization feels forced to maximize employee efficiency because of financial constraints. For example, Nursing Homes often receive Medicaid funding. Medicaid pays such a low daily rate that the administration is pressed to minimize staffing in comparison to the number of residents served. While trying to make a profit is completely understandable, the end result is one lonely CNA being responsible for all of the care needs of 9-12 people. When you have been told that you must have 10 people up, showered, dressed and ready for breakfast by 8:00 a.m. you can bet that grandma’s needs as a person aren’t really being considered. How could they be? However, it’s not the CNA’s fault, it’s the organization’s fault. Administrator’s must make tough financial decisions to ensure that every resident receives “person-centered” care.

In addition to working within financial constraints, there are is another hindrance to person centered care. That hindrance can be referred to as, “the medical model.” The medical model assumes that the medical professional knows what is best for the patient and therefore needs little to no input from that person about the type of care they will receive. Doctor knows best, you know! While no one doubts the superior medical knowledge of the medical provider, we still have to make distinctions for the differences in people. Person centered care therefore focuses on the individual.

In order for caregivers to be successful with the residents they serve, they must become expert at person centered care. In person centered care, the individual and their unique needs come first. Human interaction is the key. Interacting on a personal level allows caregivers to discover what their residents really need and become empowered to help the person get those needs met. In order to make this a reality, administrators must figure out a way to provide staffing ratios that facilitate having the necessary time for human interaction. A good guideline might be staff members having time to not only provide for direct care needs, but also time to interact with the resident on a personal level. Interaction not only makes the resident feel better but also allows for questioning and probing to determine other previously undisclosed needs. How many residents are receiving care day by day based upon medical documentation and clinical plans which are wholly unknown by the resident, yet continue on day after day?

At Intellegis we provide a 3:1 staffing ratio. Although this ratio is less profitable, it allows our staff the much needed time to care for the person, as a person. Important conversations can occur which serve as a guide to providing future care. We feel like we owe that to the person. I’m sure you would expect the same for your loved ones in whatever setting they may find themselves. A good question to ask providers before agreeing to residential support is, “what is your staffing ratio?” The answer to that question will give you an indicator as to whether your family member will have an opportunity to receive person centered care or will simply receive care dictated by staffing ratio constraints and busy clinician input. Who cares about person centered care? We do, that’s who!

Working in a residential facility for people with acquired brain injuries means we encounter many behaviors during the course of a day. Sometimes people scream and curse at the staff, sometimes they threaten with violence and at times may even become physically aggressive! And while this is often nerve-wracking for all involved, there is often a simple common-sense solution that we fail to employ. But, before I get to the simple solution, let’s first think of behavior in terms of something people use to “get to” or “get away” from something. And adding to that, let’s consider an example of how almost all of us respond in certain situations.

Imagine that you are peacefully living in your own home and suddenly become a little hungry. How would you handle it? My guess is that you would walk into the kitchen, open the fridge and grab a snack. Then you would return to your favorite chair, munch on your snack while you finished watching “Parenthood.” Simple…easy..no worries, right? Now imagine a similar scenario but you are living in a group home for people with certain disabilities. You feel a little hungry and walk into the kitchen to grab a snack. But this time you are met by a staff member with an agitated look on his face who promptly informs you, “Sorry the kitchen is closed bud!” Imagine! The kitchen is closed? All eating possibilities are suspended until tomorrow? Imagine! What would you do in that scenario? My guess is that even absent an acquired brain injury you would start to escalate and yell and even demand, by God, that someone better get you a snack or there is going to be hell to pay! And chances are, if you made enough of a scene, someone would reward your behavior with the food you requested, complete with requesting assurances from you that next time you would obey the kitchen “rules” etc., etc!

So, doesn’t it make complete sense to you that given such constraints a person would exhibit certain negative behaviors? Yet for some reason we falsely conclude that a person with certain deficits should somehow feel differently! I think if we as Managers and Administrators fall into the trap of putting our residents into any category different than the general group “human” we will end up dreaming up ideas and rules that fail to take into consideration basic human needs. And the most common reason for a person to escalate and demonstrate negative behaviors is not getting their needs or perceived needs met. So the first question we need to ask ourselves, when challenged with negative behaviors, is what need does this person have (or perceive they have) that we aren’t helping them to meet.

Here is another common scenario. A resident approaches the staff and says I need to go to the store. The staff typically respond with some answer that states in one form or another – no! The responses could be “it isn’t your shopping day” or “we don’t have the staff available to take you to the store right now” or “we are just about to eat dinner” or even “you just went to the store yesterday!” Yet what do all of these responses have in common? They all represent the answer – no! And worse, they communicate that we aren’t really concerned with what your need is as much as we are concerned with following our schedule or plans. Screaming follows, we write reports and the day ends like yesterday ended.

In order to stop or greatly reduce the cycle of negative behaviors; behaviors people are using to get something they want or get away from something they don’t want, our number one job is to find out what the need is and then work creatively if necessary to get that need met! Oh sure, I get the dollars and cents of business. I understand the limitations of staffing and staff costs. I even appreciate the necessity for rules or guidelines to help things run more smoothly and efficiently. You bet! But even more than that, I understand people and how they respond when their important needs aren’t being met (even if it just their perceptions).

So the simple solution to escalating behaviors is to work with your staff to become expert at finding out what the need is and then assuring your customers that it will be met. Our motto here at Intellegis is that we never say “no” to a request. We may say, okay let me go talk to the supervisor and figure out how we can help you, but we never give answers that can be interpreted as “no.” Why? Because a no answer to a perceived need will almost always end in escalated behaviors which in most cases we end up meeting anyway as a response to the madness that just ensued after we said no!

So do yourselves and those people you serve a favor. Instead of getting caught up in the yelling and the cursing and the threats, respond calmly in a way that communicates your sincere desire to help the person get their needs met. And you know what you will discover? Old such and such really isn’t such a bad person after all!

A Message from the Owner, Janette Thompson

Welcome to Intellegis! Intellegis is a Latin word meaning understanding. Our facility is unique; it was especially created to address the need for specialized services for people with acquired brain injuries. We are a team of professionals with the skills to understand our residents, and we can’t wait to start!

We provide residential services, therapeutic day activities, respite and temporary crisis care, behavioral and occupational support, a monthly support group, and more; all to enhance the everyday life experience. We know how important it is to create new memories to enrich life’s journey. We look forward to meeting you, and being a valuable resource in the community for brain injury support. We are your specialists, and are always open to new ideas and suggestions. Contact us!

Hello Intellegis visitor! We are so excited for 2012! We can’t wait to welcome new residents into our facility, and be a strength to you- a member of the brain injury community! As we get started this year we ask for a bit of patience with our office hours- we are here 5 days a week, but have limited hours until we get the facility up and running. You can always leave a message- we check them Monday thru Friday!

Please join us on the first Thursday of every month for a Brain Injury Support Group activity! We’ll be meeting at 6:30 for social activities. Future events include making cookies, bowling, a game night, dancing, exercise basics, a drawing class, and more. We look forward to seeing you there! As always, bring ideas of activities you’d like to participate in- we would love for you to share your talents! And remember- our activities are free! Soon we will also be adding a caregiver aspect to our support group activities.

We can’t wait to see you again, or to meet you! Call me with any questions, and happy 2012!
-Gina Lee